Pickering T G
Hypertension Center, New York Presbyterian Hospital-Cornell University Medical Center, 520 East 70th Street, New York, NY 10021, USA.
Heart Dis. 2000 Mar-Apr;2(2):S18-22.
Diabetes is twice as common in hypertensive patients than in the general population, and is a major cause of cardiovascular morbidity. Diabetes is the most common cause of end-stage renal disease in the United States, and is primarily responsible for the 9% increase in prevalence of end-stage renal disease during the past 10 years. However, there is evidence that tight blood-pressure control can reduce the vascular complications of diabetes. This reduction was demonstrated in the United Kingdom Prospective Diabetes Study, in which patients who were randomized to a tight blood-pressure control group had 24% fewer vascular complications (including strokes and diabetic retinopathy) than patients in usual-care groups. Thus, the target goal for blood pressure in patients with diabetes is 130/85 mmHg. Microalbuminuria is an early marker of diabetic nephropathy, and is most pronounced in patients whose 24-hour blood pressure shows a nondipping pattern (failure of the blood pressure to fall at night). The prevalence of nondipping blood pressure is increased in patients with diabetes and in patients with renal disease due to other causes. Further, there is evidence that patients with nondipping blood pressure show more rapid deterioration of renal function than patients with dipping blood pressure. High nocturnal pressure in patients with nondipping blood pressure may accelerate glomerular damage. For example, studies of animals with diabetes have shown that the afferent glomerular arteriole is dilated when compared with the efferent arteriole, thereby exposing the glomerulus to the systemic arterial pressure. Numerous studies have shown that angiotensin-converting enzyme (ACE) inhibitors are superior to some antihypertensive agents (particularly beta blockers and diuretics) in the prevention of renal damage. This observation is based on results of a metaanalysis that demonstrated a 9%/year glomerular filtration rate decrease in patients taking beta blockers or diuretics, but only a 1%/year decrease in patients taking ACE inhibitors. The role of calcium channel blockers is more controversial, but there is evidence to suggest that nondihydropyridine calcium channel blockers may confer the same benefit as ACE inhibitors. Alpha blockers and angiotensin-receptor blockers show promise, but have been less widely studied.
糖尿病在高血压患者中的发病率是普通人群的两倍，是心血管疾病发病的主要原因。糖尿病是美国终末期肾病最常见的病因，也是过去10年终末期肾病患病率增长9%的主要原因。然而，有证据表明严格控制血压可减少糖尿病的血管并发症。这一减少在英国前瞻性糖尿病研究中得到了证实，在该研究中，随机分配到严格血压控制组的患者比常规治疗组的患者血管并发症（包括中风和糖尿病视网膜病变）少24%。因此，糖尿病患者的血压目标值为130/85 mmHg。微量白蛋白尿是糖尿病肾病的早期标志物，在24小时血压呈非勺型模式（夜间血压不降）的患者中最为明显。糖尿病患者和其他原因导致的肾病患者中非勺型血压的患病率增加。此外，有证据表明，非勺型血压患者的肾功能恶化速度比勺型血压患者更快。非勺型血压患者的夜间高血压可能会加速肾小球损伤。例如，对糖尿病动物的研究表明，与出球小动脉相比，入球小动脉扩张，从而使肾小球暴露于体循环动脉压之下。大量研究表明，在预防肾脏损害方面，血管紧张素转换酶（ACE）抑制剂优于某些抗高血压药物（特别是β受体阻滞剂和利尿剂）。这一观察结果基于一项荟萃分析的结果，该分析表明，服用β受体阻滞剂或利尿剂的患者肾小球滤过率每年下降9%，而服用ACE抑制剂的患者仅下降1%。钙通道阻滞剂的作用更具争议性，但有证据表明非二氢吡啶类钙通道阻滞剂可能与ACE抑制剂具有相同的益处。α受体阻滞剂和血管紧张素受体阻滞剂显示出前景，但研究较少。
